SPAY NEUTER NETWORK
STERILIZATION AUTHORIZATION AND RELEASE FORM
THIS IS A LEGALLY BINDING DOCUMENT, READ BEFORE SIGNING.
Procedure and Risks
Your animal(s) is undergoing spay and/or neuter surgery. There are natural risks involved with the surgery itself, and the use of
anesthetics and other drugs. Injury and death can result from the surgery, any related procedures, and from complications following
surgery. SPAY NEUTER NETWORK does not conduct pre-operative blood tests and your pet may have unknown disorders of the
liver, kidney, blood, and/or other system. Such disorders may increase your pets’ anesthetic risks. The following conditions increase
the possibility of complications or death before, during, or after surgery:
• Animals in advanced stages of pregnancy
• Animals in heat
• Animals of advanced age
• Animals suffering from worms, leukemia, or other diseases or injury
Your dog/cat will receive a small tattoo on their underside to show that they have been sterilized.
Consent
I am 18 years of age or older and the owner or authorized agent responsible for the animal(s) described below. I understand the risks
involved in my animal’s surgery and that injury or death may occur. I assume full responsibility for the consequences that may arise.
I authorize SPAY NEUTER NETWORK, its staff members, volunteers and/or agents to receive, transport, and perform any and all
necessary services for the sterilization surgery to be performed upon the animal(s) named below: Name(s), ages(s) and description of
animal(s):
Pet # 1 __________________________________________________Pet # 2 ___________________________________________
Pet # 3___________________________________________________Pet # 4 __________________________________________
To my knowledge this animal(s) is in good health.
If the animal(s) dies as a result of surgery, I will be notified and the animal may be picked up by me or the remains will be taken care of
in accordance with state laws and the policy of this clinic. I understand that I am responsible for paying all costs of services rendered,
including the cost of keeping and/or disposing of animals.
I understand that SPAY NEUTER NETWORK is not responsible for complications resulting from my failure to follow post-operative
instructions; my request to release the animal early, while still showing signs of sedation; my failure to keep the animal indoors for
seven (7) days; or for contagious diseases for which the animal was not previously vaccinated, including kennel cough.
I understand that there is some risk of a moving vehicle accident when my animal is being transported to the surgery clinic and hold
SPAY NEUTER NETWORK and its driver harmless from any liability resulting from such accident.
I acknowledge that no guarantees or assurances have been made to me regarding the results of this surgery.
Independent Veterinarians
I acknowledge that the veterinarians treating my animal(s) do not work for SPAY NEUTER NETWORK. The veterinarians are engaged
in the private practice of veterinary medicine and are not employees or agents of SPAY NEUTER NETWORK. SPAY NEUTER
NETWORK is not responsible for the judgment or conduct of the veterinarians who treat or provide services to my animal(s). SPAY
NEUTER NETWORK does not exercise control of any nature over any procedures performed by the attending veterinarian and I will
not hold SPAY NEUTER NETWORK, it’s staff, volunteers, or agents liable or responsible in any manner for any complications that may
arise during surgery or as a result of the surgery.
The veterinarian may perform additional treatments or procedures that he or she feels are important to the health of the animal(s).
These additional treatments or procedures are beyond the scope of SPAY NEUTER NETWORK’s services and additional charges may
apply.
The veterinarian may also refuse to perform any procedure on any animal for any reason. Such refusal is at the sole discretion of the
attending veterinarian. I also understand and acknowledge that SPAY NEUTER NETWORK may refuse to accept any animal that, in
Rev. 02/25/2017
its opinion, could jeopardize the safety of any other animal or person. For any pet declined for medical or safety reasons you will be
charged for an intake fee of $15 per pet.
I certify that this animal(s) has had no food for at least ten (10) hours prior to surgery.
I understand that I MUST pick up this animal(s) on the day and time indicated by SPAY NEUTER NETWORK personnel. Failure to
pick up within one day will be construed as abandonment. An overnight charge of $20 per night will be assessed to all owners who do
not pick up their animal(s) by 5:00 pm at the main clinic, 3:00 pm at the mobile clinics, or the designated time on transport. The staff
will NOT wait for your return, no exceptions.
TO THE BEST OF MY KNOWLEDGE AND BELIEF, THIS ANIMAL HAS NOT BITTEN ANY PERSON DURING THE PAST FIFTEEN
(15) DAYS PRECEDING THIS DATE.
MICROCHIPS are the best way to recover your pets when they become lost. SPAY NEUTER NETWORK offers this service for only
$15.00. Would you like us to MICROCHIP your pet today (please initial) __________ YES __________NO (adopted pets in TX must
be chipped).
DOG OWNERS please initial one of the following:
While required for dogs 5 years and older, a pre-anesthetic occult Heartworm test is recommended on all dogs over 7 months before
elective surgeries. Heartworm disease can lead to severe complications, and even death, under or after anesthesia/surgery.
_____ I, owner or authorized agent of the dog, request a pre-surgical occult heartworm test for my dog for an additional fee of $16.50.
_____ I, the owner (or authorized agent) decline the pre-surgical heartworm test and fully understand the additional risks involved if my
dog is heartworm positive.
DOG OWNERS please initial that you have been informed of the following:
______The pain medication used after surgery on Dogs is Ketoprofen. This is a non-steroidal anti-inflammatory drug (NSAID) that is
labeled for use in horses. Use in dogs is considered “off label” but is not uncommon in veterinary medicine. Side effects of this drug,
as in all NSAIDs, can include gastrointestinal upsets and rarely, kidney dysfunction. If you do not wish to have Ketoprofen used, an
alternative pain medication can be given for an extra charge. Please initial that you have been informed that this is an off label use of
the drug.
Your dog has been given two medications today for pain; one that lasts for six hours and another that lasts for approximately 24 hours.
Some dogs may experience pain beyond 24 hours. You may purchase extra pain medication to take home for an additional fee.
CAT OWNERS please initial one of the following:
A pre-anesthetic FELV/FIV test is recommended before elective surgeries. This disease can lead to severe complications, and even
death, under or after anesthesia/surgery.
_____ I, owner or authorized agent responsible for the cat request a FELV/FIV test for my cat for an additional fee of $19.80.
_____ I, the owner or authorized agent responsible for the cat decline the pre-surgical FELV/FIV test and fully understand the
additional risks if my cat is FEL/FIV positive.
DONATIONS PLEASE SPAY NEUTER NETWORK is a nonprofit charity that works on donations. Our cost to perform a cat surgery is
$75 and a dog surgery is $105. Please consider giving a donation of _________$1 _________$5 _________$10
________Other. It will be added to your invoice. Thank you.
By signing below I hereby confirm that the procedures to be performed have been fully explained to me to my satisfaction and I have
read and understand the contents of this document. Also your signature allows SNN to use you and/or your pet’s picture in
promotional material.
SIGNATURE________________________________________________________________________DATE____________________
WE ACCEPT CASH, MASTERCARD or VISA PAYMENT ONLY
Rev. 02/25/2017